Parafunction Yes ( ) No ( )

Exposure to radiation Yes ( ) No ( )

Occlusion problems Yes ( ) No ( )

Yes ( ) No ( )Poor oral hygiene Drug, tobacco or alcohol use Yes ( ) No ( )

Pre existing Diseases (specify) Yes ( ) No ( )

Diseases Historic (specify) Yes ( ) No ( )

Arterial Hypertension Yes ( ) No ( )

Coronary or heart disease Yes ( ) No ( )

Medications in use (specify) Yes ( ) No ( )

Factors interfering with bone or soft tissue healing (specify) Yes ( ) No ( )

Psychological or neurological disturbes Yes ( ) No ( )

1 Clinical Check List

Professional in charge:

Patient name or initials:

Gender: Birth date (dd/mm/yy): / /

Anamnesis

Performed Exams

Complete oral diagnosis Yes ( ) No ( )

Available images (specify) Yes ( ) No ( )

Other exams (specify) Yes ( ) No ( )

Comments

Submission date (dd/mm/yy): / /

Grafting (specify) Yes ( ) No ( )

Provisional prosthesis Yes ( ) No ( )

Sinus lift Yes ( ) No ( )

Immediate loading Yes ( ) No ( )

Delayed loading Yes ( ) No ( )

Early loading Yes ( ) No ( )

Adoption of recommended surgical protocol Yes ( ) No ( )

Post surgery images Yes ( ) No ( )

Use of original P-I products Yes ( ) No ( )

2 Clinical Check List

CLINICAL PROCEDURES

Pre medication

Post medication

Procedures

Comments

3 Clinical Check List

Implant and Abutment Register

Traceability Tag Implant

and AbutmentLOT

Installation(dd/mm/yy)

Uncovering (dd/mm/yy)

Prosthesis (dd/mm/yy)

Loss (dd/mm/yy)

Position(Tooth

Number)

Bone Type (I, II, III, IV)

Torque (Ncm)

Affix tag here or insert product code and LOT

Affix tag here or insert product code and LOT

Affix tag here or insert product code and LOT

Affix tag here or insert product code and LOT

Affix tag here or insert product code and LOT

Affix tag here or insert product code and LOT

Affix tag here or insert product code and LOT

Affix tag here or insert product code and LOT

Affix tag here or insert product code and LOT

Affix tag here or insert product code and LOT

4 Clinical Check List

Additional information related to patient treatment:

In your opinion, what was the reason for product loss?

Would you like Clinical Support?

Yes ( ) No (

Date Description

)

Was the patient injured or at risk?

Yes ( ) No ( )

Some programs may not be available in your region. Please check with your authorized Distributor or Subsidiary.

www.pibranemark.com/guarantee

Signature | Stamp of the professional responsible for the patient

CHEC

K LI

ST-0

02-E

NG

-201

5-05

-04

Term of Guarantee - Instructions and Conditions for replacement of products

The analysis process and replacement of products is limited to Implants and Abutments within 30 days from the date of loss.

§ The Guarantee is limited to product replacement in case of loss, and applies only to P-I Implants and P-I Abutments used exclusively with P-I genuine Implants. Replacement products shall be equivalent the original product.

§ P-I reserves the right to require additional information in order to supplement the information contained in the Clinical Check List prior to replacing any product. If the Clinical Check List and other information provided by the requestor is insufficient to identify the product as a genuine P-I product (for example , product codes or LOT numbers), the replacement may be denied at P-I’s sole discretion.

§ The LifeTime Guarantee does not cover, and P-I expressly disclaims liability for, any of the following: out-of-pocket expenses, additional products or materials, or clinician or laboratory service fees (including but not limited to regenerative materials, third party Abutments, crowns and other prostheses, and additional surgeries), losses or expenses due to trauma, accident, patient health status or medical conditions, incomplete or inadequate clinical procedures, external causes, or the non-observance of the product’s Instructions for Use and contraindications.

§ P-I reserves the right to modify or cancel the LifeTime Guarantee, or any of its terms, in whole or in part at any time and without prior notice. By purchasing and accepting P-I products, and by signing this Clinical Check List form, you agree to abide by these terms and conditions.

Completion of this form does not constitute an admission that medical personnel, distributor, manufacturer, or product caused or contributed to the occurrence. Important: Please do not return parts. Cases in which lost products are requested must only be returned with prior formal approval. In these cases, products must be cleaned, disinfected and sterilized.